Association between concurrence of multiple risk factors and under-5 mortality: a pooled analysis of data from Demographic and Health Survey in 61 low-and-middle-income countries.

Background: Exposure to multiple risk factors is prevalent in low-and middle-income countries (LMICs), challenging one-directional strategies to address preventable under-5 mortality (U5M). This study aims to assess the associations between concurrence of multiple risk factors and U5M in LMICs. Methods: We extracted data from the Demographic and Health Surveys conducted between 2010 and 2021 across 61 LMICs. Our primary outcome was U5M, defined as deaths from birth to 59 months. Binary logistic regression model was applied to ascertain the association between U5M and a total of 20 critical risk factors. Upon identifying the risk factors demonstrating the strongest associations, we investigated the simultaneous presence of multiple risk factors in each individual and assessed their combined effects on U5M with logistic regression models. Findings: Of the 604,372 under-5 children, 18,166 (3.0%) died at the time of the survey. Unsatisfied family planning needs was the strongest risk factor for U5M (odds ratio [OR]: 2.0, 95% confidence interval [CI]: 1.9-2.1), followed by short birth interval (<18 months; OR: 2.0, 95% CI: 1.9-2.1), small birth size (OR: 2.0, 95% CI: 1.8-2.1), never breastfed or delayed breastfeeding (OR: 2.0, 95% CI: 1.9-2.0), and low maternal education (OR: 1.6, 95% CI: 1.4-1.8). 66.7% (66.6%-66.8%) of the children had 2 or more leading risk factors simultaneously. Simultaneous presence of multiple leading risk factors was significantly associated with elevated risk of U5M and children presenting with all 5 leading risk factors exhibited an exceedingly high risk of U5M (OR: 5.2, 95% CI: 4.3-6.3); a dose-response relationship between the number of risk factors and U5M was also observed-with the increment of numbers of leading risk factors, the U5M showed an increasing trend (p-trend < 0.001). Interpretation: Exposure to multiple risk factors is very common in LMICs and underscores the necessity of developing multisectoral and integrated approaches to accelerate progress in reducing U5M in line with the SDG 3.2. Funding: This research is funded by Research Fund, Vanke School of Public Health, Tsinghua University.

Explaining changes in educational disparities in competent maternal health care services in urban and rural areas in Ethiopia.

Introduction: Aggregate statistics of maternal health care services have improved in Ethiopia. Nevertheless, the country has one of the lowest Universal Health Coverage (UHC) service coverage indices, with slight improvement between 2000 and 2019. There are disparity studies that focus on a single dimension of inequality. However, studies that combine multiple dimensions of inequality simultaneously may have important policy implications for closing inequalities. In this study, we investigated education inequalities in the receipt of maternal health care services in rural and urban areas separately, and we examined whether these inequalities decreased, increased, or remained unchanged. Methods: The data for the study came from the 2011 and 2016 Ethiopia Demographic and Health Surveys. Using women's education as a dimension of inequality, we separately analyzed inequalities in maternal health care services in urban and rural settings. Inequalities were measured through the Erreygers concentration index, second differences, and Relative Index of Inequality (RII). Whether inequalities changed over time was analyzed by relative and absolute measures. An Oaxaca-type decomposition approach was applied to explain changes in absolute disparities over time. Results: There were glaring educational disparities in maternal health care services in urban and rural areas, where the services were more concentrated among women with better schooling. The disparities were more severe in urban than in rural areas. In urban areas, skilled birth service was the most unequal in both periods. Disparities in rural places were roughly similar for all services except that in 2011, postnatal care was the least unequal, and in 2016, skilled birth was the most unequal services. Trend analyses revealed that disparities significantly dropped in urban by absolute and relative measures. Conversely, in rural regions, the disparities grew by the concentration index measure for most services. The RII and second differences presented conflicting results regarding whether the gaps were increasing, shrinking, or remaining the same. Conclusion: Substantial disparities in maternal health care services remained and even increased, as in rural areas. Different and targeted strategies are needed for urban and rural places to close the observed educational inequalities in these areas.

Decomposition analysis of women's empowerment-based inequalities in the use of maternal health care services in Ethiopia: Evidence from Demographic and Health Surveys.

BACKGROUND: The use of maternal health care services tends to rise with women's empowerment. However, disparities in the use of maternal health care services in Ethiopia that are founded on women's empowerment are not sufficiently addressed. In light of women's empowerment equity stratifier, this study seeks to assess inequalities in the uptake of maternal health care services (early antenatal care, four or more antenatal care and postnatal care services). METHODS: Drawing on data from the four rounds of Ethiopia Demographic and Health Surveys (EDHSs) conducted between 2000 and 2016, we conducted analysis of inequalities in utilization of maternal health care services using women's empowerment as equity stratifier. We utilized concentration index and concentration curve for assessing the inequalities. We used clorenz and conindex Stata modules to compute the index and curve. Decomposition of the Erreygers normalized concentration index was done to explain the inequalities in terms of other variables' percent contributions. Complex aspect of the EDHSs data was considered during analysis to produce findings consistent with the data generating process. All analyses were done using Stata v16. RESULTS: Utilization of maternal health care services was inequitably distributed between empowered and poorly empowered women, with women in the highly empowered category taking more of the services. For instance, the Erreygers index for quality ANC are 0.240 (95% CI 0.207, 0.273); 0.20 (95% CI 0.169, 0.231) and 0.122 (95% CI 0.087, 0.157), respectively, for the attitude towards violence, social independence and decision-making domains of women's empowerment. Inequalities in the distribution of other variables like wealth, education, place of residence and women's empowerment itself underpin the inequalities in the utilization of the services across the women's empowerment groups. CONCLUSIONS: Equity in maternal health care services can be improved through redistributive policies that attempt to fairly distribute the socioeconomic determinants of health such as wealth and education between highly and poorly empowered women.

Inequalities in childhood stunting: evidence from Sudan multiple indicator cluster surveys (2010-2014).

BACKGROUND: Leaving no one behind has been an important marker of the Sustainable Development Goals. Closing the gap in malnutrition between children of different backgrounds aligns well with the tenet of this international agenda. To this end, high-quality evidence of the magnitude and trends of socioeconomic and geographic related existing inequalities in the childhood stunting among Sudanese children emanate from this study help for policy maker and planners to design and implement effective interventions to narrow down inequality. METHODS: We used the World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) for our analysis of stunting inequality. Following standard equity analysis methods recommended by the WHO, we performed the disaggregated analysis of stunting across five equity stratifiers: Wealth, education, residence, sex, and sub-national regions. Then, we summarized stunting inequality through four measures of inequality: Difference, Ratio, Slope Index of Inequality (SII), and Relative Index of Inequality (RII). The point estimates of stunting were accompanied by 95% confidence intervals to measure the statistical significance of the findings. RESULTS: In this study, the national average childhood stunting prevalence was increased by 4% from 2010 to 2014. The findings revealed stark inequalities in stunting in all the studied dimensions of inequality. Huge inequality has existed along the wealth quintiles. Simple difference measure for education was increased by four points and simple relative measure decreased by one point for economic status. CONCLUSIONS: Sex, residence and, geographically related inequalities remain unchanged over time, while economic status and educational inequality had seen a change by some inequality measures over the same time period.

Trends in socio-economic, sex and geographic disparities in childhood underweight in Mauritania: evidence from Multiple Indicator Cluster Surveys (2007-2015).

BACKGROUND: Underweight is one of the largest contributors to child morbidity and mortality and is considered to be the largest contributor to the global burden of diseases in low-and middle-income countries. In Mauritania, where one-fifth of children are underweight, there is a dearth of evidence on socio-economic, sex and geographic disparities in childhood underweight. As a result, this study aimed at investigating the socio-economic, sex and geographic disparities in childhood underweight in Mauritania. METHODS: Using the World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) software, data from the Mauritania Multiple Indicator Cluster Surveys (MICSs) conducted between 2007 and 2015 were analysed. Childhood underweight was disaggregated by five equity stratifiers: education, wealth, residence, region and sex. In addition, absolute and relative inequality measures, namely difference (D), population attributable risk (PAR), ratio (R) and population attributable fraction (PAF) were calculated to understand inequalities from wider perspectives. Corresponding 95% confidence intervals (CIs) were computed to measure statistical significance. RESULTS: Substantial absolute and relative socio-economic, sex and geographic disparities in underweight were observed from 2007 to 2015. Children from the poorest households (PAR=-12.66 [95% CI -14.15 to -11.16]), those whose mothers were uneducated (PAF=-9.11 [95% CI -13.41 to -4.81]), those whose mothers were rural residents (R=1.52 [95% CI 1.37 to 1.68]), residents of HodhCharghy (PAF=-66.51 [95% CI -79.25 to -53.76]) and males (D=4.30 [95% CI 2.09 to 6.52]) experienced a higher burden of underweight. Education-related disparities decreased from 2007 to 2015. The urban-rural gap in underweight similarly decreased over time with the different measures showing slightly different reductions. Wealth-driven disparities decreased marginally from 2011 to 2015. The sex-based and regional disparities increased, at least on average, over the 8-y intersurvey period. CONCLUSIONS: The burden of underweight was significantly higher among children from disadvantaged subpopulations, those with uneducated and poorest/poor mothers, those living in rural areas and those living in HodhCharghy. Special nutrition intervention and efforts focused on these deprived subpopulations are required to reduce childhood morbidity and mortality associated with underweight and help achieve the Sustainable Development Goals.

Socioeconomic, sex and area related inequalities in childhood stunting in Mauritania: Evidence from the Mauritania Multiple Indicator Cluster Surveys (2007-2015).

INTRODUCTION: The prevalence of stunting in under five children is high in Mauritania. However, there is a paucity of evidence on the extent and the overtime alteration of inequality in stunting. To this end, we did this study to investigate stunting inequality and the change with time using three rounds of Mauritania Multiple Indicator Cluster Surveys. The evidence is important to inform implementation of equitable nutrition interventions to help narrow inequality in stunting between population groups. METHODS: World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) was used in the analysis of stunting inequality. Following standard equity analysis methods recommended by the WHO, we performed disaggregated analysis of stunting across five equity stratfiers: Wealth, education, residence, sex and sub-national regions. Then, we summarized stunting inequality through four measures of inequality: Difference, Ratio, Population Attributable Fraction and Population Attributable Risk. The point estimates of stunting were accompanied by 95% confidence intervals to measure the statistical significance of the findings. RESULTS: The national average of childhood stunting in 2007, 2011 and 2015 was 31.3%, 29.7% and 28.2%, respectively. Glaring inequalities in stunting around the five equity stratifiers were observed in all the studied periods. In the most recent survey included in our study (2015), for instance, we recorded substantial wealth (PAF = -33.60; 95% CI: -39.79, -27.42) and education (PAF = -5.60; 95% CI: -9.68, -1.52) related stunting inequalities. Overall, no substantial improvement was documented in wealth and sex related inequality in stunting between 2007 and 2011 while region-based inequality worsened during the same time periods. CONCLUSIONS: The burden of stunting appeared to be heavily concentrated among children born to socioeconomically worse-off women, women who live in rural settings and certain subnational regions. Targeted nutrition interventions are required to address drivers of stunting embedded within geographic and socioeconomic contexts.

Sub-regional disparities in the use of antenatal care service in Mauritania: findings from nationally representative demographic and health surveys (2011-2015).

BACKGROUND: Skilled antenatal care (ANC) has been identified as a proven intervention to reducing maternal deaths. Despite improvements in maternal health outcomes globally, some countries are signaling increased disparities in ANC services among disadvantaged sub-groups. Mauritania is one of sub-Saharan countries in Africa with a high maternal mortality ratio. Little is known about the inequalities in the country's antenatal care services. This study examined both the magnitude and change from 2011 to 2015 in socioeconomic and geographic-related disparities in the utilization of at least four antenatal care visits in Mauritania. METHODS: Using the World Health Organization's Health Equity Assessment Toolkit (HEAT) software, data from the 2011 and 2015 Mauritania Multiple Indicator Cluster Surveys (MICS) were analyzed. The inequality analysis consisted of disaggregated rates of antenatal care utilization using four equity stratifiers (economic status, education, residence, and region) and four summary measures (Difference, Population attributable risk, Ratio and Population attributable fraction). A 95% Uncertainty Interval was constructed around point estimates to measure statistical significance. RESULTS: Substantial absolute and relative socioeconomic and geographic related disparities in attending four or more ANC visits (ANC4+ utilization) were observed favoring women who were richest/rich (PAR = 19.5, 95% UI; 16.53, 22.43), educated (PAF = 7.3 95% UI; 3.34, 11.26), urban residents (D = 19, 95% UI; 14.50, 23.51) and those living in regions such as Nouakchott (R = 2.1, 95% UI; 1.59, 2.56). While education-related disparities decreased, wealth-driven and regional disparities remained constant over the 4 years of the study period. Urban-rural inequalities were constant except with the PAR measure, which showed an increasing pattern. CONCLUSION: A disproportionately lower ANC4+ utilization was observed among women who were poor, uneducated, living in rural areas and regions such as Guidimagha. As a result, policymakers need to design interventions that will enable disadvantaged subpopulations to benefit from ANC4+ utilization to meet the Sustainable Development Goal (SDG) of reducing the maternal mortality ratio (MMR) to 140/100, 000 live births by 2030.

Observed magnitude and trends in socioeconomic and geographic area inequalities in obesity prevalence among non-pregnant women in Chad: evidence from three waves of Chad demographic and health surveys.

BACKGROUND: While the prevalence of obesity is increasing worldwide, the growing rates of overweight and obesity in developing countries are disquieting. Obesity is widely recognized as a risk factor for non-communicable diseases (NCDs), including diabetes, cancer and cardiovascular diseases. Available evidence on whether obesity has been more prevalent among higher or lower socioeconomic groups, across regions and urban-rural women's are inconsistent. This study examined magnitude of and trends in socioeconomic, urban-rural and sub-national region inequalities in obesity prevalence among non-pregnant women in Chad. METHOD: Using cross-sectional data from Chad Demographic and Health Surveys (DHSs) conducted in 1996, 2004 and 2014; we used the World Health Organization (WHO) Health Equity Assessment Toolkit (HEAT) to analyze socio-economic, urban-rural and regional inequalities in obesity prevalence among non-pregnant women aged 15-49 years. Inequalities were assessed using four equity stratifiers namely wealth index, educational level, place of residence and subnational region. We presented inequalities using simple and complex as well as relative and absolute summary measures such as Difference (D), Population Attributable Risk (PAR), Population Attributable Fraction (PAF) and Ratio (R). RESULTS: Though constant pattern overtime, both wealth-driven and place of residence inequality were observed in all three surveys by Difference measure and in the first and last surveys by Ratio measure. Similarly, including the recent survey (D = -2.80, 95% CI:-4.15, - 1.45, R = 0.37, 95% CI: 0.23, 0.50) absolute (in 1996 & 2014 survey) and relative (in all three surveys) educational status inequality with constant pattern were observed. Substantial absolute (PAR = -2.2, 95% CI: - 3.21, - 1.34) and relative (PAF = - 91.9, 95% CI: - 129.58, - 54.29) regional inequality was observed with increasing and constant pattern by simple (D) and complex (PAR, PAF) measures. CONCLUSION: The study showed socioeconomic and area-based obesity inequalities that disfavored women in higher socioeconomic status and residing in urban areas. Prevention of obesity prevalence should be government and stakeholders' priority through organizing the evidence, health promotion and prevention interventions for at risk population and general population.

Urban-rural disparities in wife-beating attitude among married women: a decomposition analysis from the 2017 Senegal Continuous Demographic and Health Survey.

BACKGROUND: Globally, intimate partner violence is one of the most common forms of gender-based violence, and wife beating is one component of intimate partner violence, with the problem being more severe among women living in rural settings. Little is known about the factors that explain the urban-rural disparity in the prevalence of wife beating attitude in Senegal. In this paper, we aimed to decompose the urban-rural disparities in factors associated with wife beating attitude among married women in Senegal. METHODS: Data were derived from the 2017 Senegal Continuous Demographic and Health Survey. We used the Blinder-Oaxaca decomposition method to decompose and explain the variation in the prevalence of disagreement to wife beating between urban and rural areas in Senegal. RESULTS: The results show that 48.9% of married women in Senegal disagreed with wife-beating. About 69% of urban women disagreed with wife beating, but only 36% of rural women disagreed with wife beating. About 68.7% of women in the sample reported that they disagreed to wife beating by their husbands for burning food and nearly 50% of women reported that they disagreed with wife beating when they refuse to have sex with their husbands. About 86% of the urban-rural disparities in disagreement with wife beating are explained in this study. Economic status (45.2%), subnational region (22.4%), women's educational status (13.3%), and husband's educational status (10.7%) accounted for 91.6% of the disparities. CONCLUSIONS: The study shows urban-rural disparities in the prevalence of wife-beating attitude (disagreement with wife beating) and this disfavored rural residents. We suggest the need for the government of Senegal to consider pro-rural equity strategies to narrow down the observed disparities. Moreover, socioeconomic empowerment and attitudinal changing interventions using existing socio-cultural institutions as platforms can be used to deliver such interventions.

Women empowerment and uptake of antenatal care services : A meta-analysis of Demographic and Health Surveys from 33 Sub-Saharan African countries.

BACKGROUND: Women empowerment has been linked to increased skilled antenatal care (ANC) service use. However, there is no evidence on the net effect of women empowerment on ANC in the Sub-saharan African (SSA) region. We aim to address the knowledge gap on whether or not women empowerment positively influences the uptake of ANC at the SSA regional level. METHODS: We analyzed the Demographic Health Survey (DHS) datasets from 33 SSA countries. Following the DHS data analysis guideline, we measured women empowerment using two indicators. The first indicator is an index, which comprises decision-making on women's own health, household purchase and visit to family or relatives whilst disagreeing statements that husband is justified in beating his wife constitutes the second indictor. We performed confounder-adjusted logistic regression analysis for the two indicators with ANC attendance in each of the 33 countries. Then, we pooled the adjusted Odds Ratios (OR) using the random effect model through the two-stage Individual Participant Data meta-analysis technique. Summary findings are reported in OR and corresponding 95 %CI and are presented in a forest plot. RESULTS: Moderately empowered women had marginally higher odd of skilled ANC service across the SSA region (aOR = 1.19; 95 %CI: 1.03, 1.38, with a prediction interval of 0.58, 2.45). Conversely, being involved in the three decisions (aOR = 1.15; 95 %CI: 0.99, 1.33, with prediction interval 0.57, 2.31), and attitude towards wife-beating (aOR = 0.97; 95 %CI: 0.88, 1.06, with prediction interval of 0.63, 1.48) had no statistically significant relationship with ANC. CONCLUSIONS: Women empowerment did not predict the use of skilled ANC in the context of the SSA region. We recommend that further studies be conducted in order to understand how women empowerment affects skilled ANC service utilization in the region.

Socioeconomic, urban-rural and sex-based inequality in infant mortality rate: evidence from 2013 Yemen demographic and health survey.

BACKGROUND: The occurrence of Infant Mortality Rate (IMR) varied globally with most of the cases coming from developing countries including Yemen. The disparity in IMR in Yemen however, has not been well dealt and therefore we examined the IMR inequality based on the most reliable methodology in order to generate evidence-based information for some program initiatives in Yemen. METHODS: Based on the World Health Organization (WHO) Health Equity Assessment Toolkit (HEAT) software, we analyzed the inequality across the different inequality dimensions in Yemen. The toolkit analyzes data stored in the WHO health equity monitor database. Simple and complex, and absolute and relative measures of inequality were calculated for the four dimensions of inequality (subpopulations) which included wealth, education, sex and residence. We computed a 95 % CI to assess statistical significance. RESULTS: The analysis included 31, 743 infants. Absolute and relative wealth-driven, education, urban-rural and sex-based inequalities were found in IMR. Higher concentration of IMR was observed among infants from the poorest/poor households (ACI=-4.68, 95 % CI; -6.57, -2.79, R = 1.61, 95 % CI; 1.18, 2.03), rural residents (D = 15.07, 95 % CI; 8.04, 22.09, PAF=-23.57, 95 % CI; -25.47, -21.68), mothers who had no formal education (ACI=-2.16, 95 % CI; -3.79, -0.54) and had male infants (PAF= -3.66, 95 % CI; -4.86, -2.45). CONCLUSIONS: Higher concentration of IMR was observed among male infants from disadvantaged subpopulations such as poorest/poor, uneducated and rural residents. To eliminate the observed inequalities, interventions are needed to target the poorest/poor households, rural residents, mothers with no formal education and male infants.

Summary measures of socioeconomic and area-based inequalities in fertility rates among adolescents: evidence from Ethiopian demographic and health surveys 2000-2016.

BACKGROUND: One of the highest rates of adolescent pregnancies in the world is in sub-Saharan Africa. Most adolescent pregnancies in the region are unintended or unwanted, due to poor access to information and services on sexual and reproductive health for adolescents. Ethiopia has high adolescent fertility rates (AFR) with disparities across socioeconomic subgroups and regions. This study assessed the magnitude and trends of socioeconomic and area-based AFR inequalities in Ethiopia. METHODS: The 2000 and 2016 Ethiopia Demographic and Health surveys (EDHS) was analyzed using the World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) software. Adolescent fertility rates were disaggregated using three equity stratifiers (economic status, education and residence) and analyzed through four summary measures (Difference (D), Population Attributable Risk (PAR), Ratio (R) and Population Attributable Fraction (PAF)) to assess inequality. To measure statistical significance, point estimates were constructed using a 95% Uncertainty Interval (UI). RESULTS: Large socio-economic and urban-rural inequalities were observed within the 16-year period. Adolescents in less well-off socio-economic groups (PAF: -62.9 [95% UI; - 64.3, - 61.4], D: 96.4 [95% UI; 47.7, 145.1]), uneducated (R: 8.5 [95% UI; 4.8, 12.2], PAR: -76.4 [95% UI;-77.7, - 75.0]) and those from rural areas (D: 81.2 [95% UI; 67.9, 94.6], PAF: -74.2 [95% UI, - 75.7, - 72.7]) had a higher chance of pregnancy and more births than their counterparts. CONCLUSIONS: Socioeconomic (education and economic status) and place of residence determine adolescents' pregnancy and childbearing. Policies and programs should be directed at preventing child marriage and early fertility so that adolescents continue to access education, sexual and reproductive health care as well as access employment opportunities. More emphasis should be placed on subpopulations with disproportionately higher adolescent pregnancy and childbirth.

Predictors of skilled birth attendance among married women in Cameroon: further analysis of 2018 Cameroon Demographic and Health Survey.

BACKGROUND: In Cameroon, maternal deaths remain high. The high maternal deaths in the country have been attributed to the low utilization of maternal healthcare services, including skilled birth attendance. This study examined the predictors of skilled birth services utilization among married women in Cameroon. METHODS: Data from the 2018 Cameroon Demographic and Health Survey was analyzed on 7881 married women of reproductive age (15-49 years). Both bivariate and multivariable logistic regression analyses were carried out to determine the predictors of skilled childbirth services. The results were presented with crude odds ratio (cOR) and adjusted odds ratio (aOR) and 95% confidence interval (CI). RESULTS: The coverage of skilled birth attendance among married women of reproductive age in Cameroon was 66.2%. After adjusting for potential confounders, media exposure (aOR = 1.46, 95% CI: 1.11-1.91), higher decision making (aOR = 1.88, 95% CI: 1.36-2.59), maternal education (aOR = 2.38, 95% CI; 1.65-3.42), place of residence (aOR = 0.50, 95% CI; 0.33-0.74), religion (aOR = 0.55, 95% CI; 0.35-0.87), economic status (aOR = 5.16, 95% CI; 2.58-10.30), wife beating attitude (aOR = 1.32, 95% CI; 1.05-1.65), parity (aOR = 0.62, 95% CI; 0.41-0.93) and skilled antenatal care (aOR = 14.46, 95% CI; 10.01-20.89) were found to be significant predictors of skilled birth attendance. CONCLUSIONS: This study demonstrates that social, economic, regional, and cultural factors can act as barriers to skilled childbirth services utilization in Cameroon. Interventions that target women empowerment, antenatal care awareness and strengthening are needed, especially among the rural poor, to reduce barriers to care seeking. Maternal healthcare services utilization interventions and policies in Cameroon need to focus on specific equity gaps that relate to socio-economic status, maternal education, and the economic empowerment of women. Such policies and interventions should also aim at reducing geographical barriers to access to maternal healthcare services, including skilled birth attendance. Due to the presence of inequities in the use of skilled birth attendance services, programs aimed at social protection and empowerment of economically disadvantaged women are necessary for the achievement of the post-2015 targets and the Sustainable Development Goals. Globally, Cameroon is one of the countries with high maternal deaths. Low utilization of maternal healthcare services, including skilled birth attendance have been found to account for the high maternal deaths in the country. This study sought to examine the factors associated with skilled childbirth services utilization among married women in Cameroon. Using data from the 2018 Cameroon Demographic and Health Survey, we found that the coverage of skilled birth attendance among married women of reproductive age in Cameroon is high. Factors such as higher decision-making power, higher maternal education, place of residence, religion, higher economic status, wife beating attitude, parity and skilled antenatal care were found to be the significant predictors of skilled birth attendance. This study has shown that socio-economic, regional and cultural factors account for the utilization of skilled childbirth services utilization in Cameroon. Interventions aimed at enhancing the utilization of skilled childbirth services in Cameroon should target women empowerment, antenatal care awareness creation and sensitization, especially among the rural poor, to reduce barriers to care seeking. Maternal healthcare services utilization interventions and policies in Cameroon need to focus on specific equity gaps that relate to socio-economic status, maternal education, and the economic empowerment of women.

Time trends in socio-economic, urban-rural and regional disparities in prevalence of obesity among non-pregnant women in Lesotho: evidence from Lesotho demographic and health surveys (2004-2014).

BACKGROUND: The growing rates of obesity in developing countries are alarming. There is a paucity of evidence about disparities of obesity in Lesotho. This study examined socioeconomic and area-based inequalities in obesity among non-pregnant women in Lesotho. METHODS: Data were extracted from the 2004, 2009 and 2014 Lesotho Demographic and Health Surveys (LDHS) and analyzed through the recently updated Health Equity Assessment Toolkit (HEAT) of the World Health Organization. Obesity prevalence was disaggregated by four equity stratifiers, namely education, wealth, residence and sub-national region. For each equity stratifier, simple and complex as well as relative and absolute summary measures were calculated. A 95% confidence interval was used to measure statistical significance of findings. RESULTS: We noticed substantial wealth-driven (D = -21.10, 95% CI; - 25.94, - 16.26), subnational region (PAR = -11.82, 95%CI; - 16.09, - 7.55) and urban-rural (- 9.82, 95% CI; - 13.65, - 5.99) inequalities in obesity prevalence without the inequalities improved over time in all the studied years. However, we did not identify educational inequality in obesity. CONCLUSIONS: Wealth-driven and geographical inequalities was identified in Lesotho in all the studied time periods while education related inequalities did not appear during the same time period. All population groups in the country need to be reached with interventions to reduce the burden of obesity in the country.

Trends of inequalities in care seeking behavior for under-five children with suspected pneumonia in Ethiopia: evidence from Ethiopia demographic and health surveys (2005-2016).

BACKGROUND: Pneumonia is a leading public health problem in under-five children worldwide and particularly in Africa. Unfortunately, progress in reducing pneumonia related mortality has been slow. The number of children with symptoms of pneumonia taken to health facilities for treatment is low in Ethiopia, and disparities among sub-groups regarding health seeking behavior for pneumonia have not been well explored in the region. This study assessed the trends of inequalities in care seeking behavior for children under five years of age with suspected pneumonia in Ethiopia. METHODS: Using cross-sectional data from the 2005, 2011 and 2016 Ethiopia Demographic and Health Surveys (DHS) and the World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT), this study investigated the inequalities in health seeking behavior for children with suspected pneumonia. Four measures of inequality were calculated: Difference, Ratio, Slope Index of Inequality and Relative Index of Inequality. Results were disaggregated by wealth, education, residence, and sex with computed 95% Uncertainty Intervals for each point estimate to determine significance. RESULTS: The percentage of under-five children with symptoms of pneumonia who were taken to a health facility was significantly lower for children in the poorest families, 15.48% (95% UI; 9.77, 23.64) as compared to children in the richest families, 61.72% (95% UI; 45.06, 76.02) in 2011. Substantial absolute (SII = 35.61; 95% UI: 25.31, 45.92) and relative (RII = 4.04%; 95% UI: 2.25, 5.84) economic inequalities were also observed. Both educational and geographic inequalities were observed; (RII = 2.07; 95% UI: 1.08, 3.06) and (D = 28.26; 95% UI: 7.14, 49.37), respectively. Economic inequality decreased from 2011 to 2016. There was no statistically significant difference between male and female under-five children with pneumonia symptoms taken to health facility, in all the studied years. CONCLUSIONS: Health care seeking behavior for children with pneumonia was lower among the poorest and non-educated families as well as children in rural regions. Policies and strategies need to target subpopulations lagging behind in seeking care for pneumonia treatment as it impedes achievement of key UN sustainable development goals (SDGs).

Trends in inequalities in childhood stunting in Ethiopia from 2000 to 2016: a cross sectional study.

BACKGROUND: The decrease in the magnitude of stunting over the past 20 years has been slow in Ethiopia. To date, in Ethiopia, the trends in and extent of inequality in stunting have not been investigated using methods suitably developed for disparity studies. This paper investigated both the extent and overtime dynamics of stunting inequality in Ethiopia over the last 17 years. METHODS: Using the World Health Organization's Health Equity Assessment Toolkit software, data from the Ethiopia Demographic and Health surveys (EDHS) were analyzed between 2000 and 2016. The inequality analysis consisted of disaggregated rates of stunting using five equity stratifiers (economic status, education, residence, region and sex) and four summary measures (Difference, Population Attributable risk, Ratio and Absolute Concentration Index). A 95% uncertainty interval was constructed around point estimates to measure statistical significance. RESULTS: The study showed that both absolute and relative inequalities in stunting exist in all the studied years in Ethiopia. The inequality disfavors children of mothers who are poor, uneducated and living in rural areas and specific regions such as Amhara. The pro-rich (R = 1.2; 1.1, 1.3 in 2000 to R = 1.7; 1.4, 2 in 2016) and pro-educated (R = 1.6; 95%UI = 1.3, 1.9 in 2000 and R = 2.3; 95%UI = 1.5, 3 in 2011) inequalities slightly increased with time. Male children bear a disproportionately higher burden of stunting, and the disparity increased between the first and the last time points (PAR = -1.5 95%UI = -2.5, -0.6 in 2000 and PAR = -2.9 95%UI = -3.9, -1.9) based on complex measures but remained constant with simple measures (R = 1; 95%UI = 0.9, 1.1 in 2000 and R = 1.1 95%UI = 1, 1.2 in 2016). Similarly, both the sub-national regional and residence-related stunting disparities generally widened over time according to some of the inequality measures. CONCLUSIONS: Stunting appeared to be highly prevalent among certain sub-groups (i.e. poor, uneducated and living in rural regions). The subpopulations experiencing excessively high stunting prevalence should be the focus of policy makers' attention as they work to achieve the WHO 40% reduction in stunting target by 2025 and the UN Agenda 2030 for Sustainable Development Goals.

Factors affecting the utilization of antenatal care services among women in Guinea: a population-based study.

INTRODUCTION: Evidence suggests that a better understanding of determinants of antenatal care (ANC) utilization is crucial to reducing maternal and child deaths. Little is known about the utilization of ANC services in Guinea. OBJECTIVE: The aim of this study was to explore factors determining utilization of skilled ANC in Guinea. METHODS: This study focused on a sample of 7812 ever married women. Using multivariate logistic regression, factors associated with the utilization of ANC were identified. The output of the multivariate logistic regression was presented using adjusted odds ratio and the corresponding 95% confidence interval (CI). RESULTS: Several factors had significant association with utilization of skilled ANC service in Guinea: having decision-making power (2.21, 95% CI: 1.63, 3.00), employment status (1.86, 95% CI: 1.39, 2.48), media exposure (1.60, 95% CI: 1.26, 2.02), maternal education (2.68, 95% CI: 1.36, 5.28), husband/partner education status (1.66, 95% CI: 1.08, 2.55), household economic status (2.19, 95% CI: 1.40, 3.44), place of residence (0.29, 95% CI: 0.16, 0.50) and ethnicity (0.40, 95% CI: 0.23, 0.69). CONCLUSIONS: These findings suggest a variety of socio-demographic and economic factors as well as media exposure are associated with women's use of ANC. Policymakers should implement appropriate measures to address the existing variations and gaps in ANC services utilization among different subgroups of women in Guinea.

Time trends, geographical, socio-economic, and gender disparities in neonatal mortality in Burundi: evidence from the demographic and health surveys, 2010-2016.

BACKGROUND: Programmatic and research agendas surrounding neonatal mortality are important to help countries attain the child health related 2030 Sustainable Development Goal (SDG). In Burundi, the Neonatal Mortality Rate (NMR) is 25 per 1000 live births. However, high quality evidence on the over time evolution of inequality in NMR is lacking. This study aims to address the knowledge gap by systematically and comprehensively investigating inequalities in NMR in Burundi with the intent to help the country attain SDG 3.2 which aims to reduce neonatal mortality to at least as low as 12 per 1000 live births by 2030. METHODS: The Burundi Demographic and Health Survey (BDHS) data for the periods of 2010 and 2016 were used for the analyses. The analyses were carried out using the WHO's HEAT version 3.1 software. Five equity stratifiers: economic status, education, residence, sex and subnational region were used as benchmark for measuring NMR inequality with time over 6 years. To understand inequalities from a broader perspective, absolute and relative inequality measures, namely Difference, Population Attributable Risk (PAR), Ratio, and Population Attributable Fraction (PAF) were calculated. Statistical significance was measured by computing corresponding 95% Confidence Intervals (CIs). RESULTS: NMR in Burundi in 2010 and 2016 were 36.7 and 25.0 deaths per 1000 live births, respectively. We recorded large wealth-driven (PAR = -3.99, 95% CI; - 5.11, - 2.87, PAF = -15.95, 95% CI; - 20.42, - 11.48), education related (PAF = -6.64, 95% CI; - 13.27, - 0.02), sex based (PAR = -1.74, 95% CI; - 2.27, - 1.21, PAF = -6.97, 95% CI; - 9.09, - 4.86), urban-rural (D = 15.44, 95% CI; 7.59, 23.29, PAF = -38.78, 95% CI; - 45.24, - 32.32) and regional (PAR = -12.60, 95% CI; - 14.30, - 10.90, R = 3.05, 95% CI; 1.30, 4.80) disparity in NMR in both survey years, except that urban-rural disparity was not detected in 2016. We found both absolute and relative inequalities and significant reduction in these inequalities over time - except at the regional level, where the disparity remained constant during the study period. CONCLUSION: Large survival advantage remains to neonates of women who are rich, educated, residents of urban areas and some regions. Females had higher chance of surviving their 28th birthday than male neonates. More extensive work is required to battle the NMR gap between different subgroups in the country.

Regional variations and socio-economic disparities in neonatal mortality in Angola: a cross-sectional study using demographic and health surveys.

BACKGROUND: Inequalities in neonatal mortality rates (NMRs) in low- and middle-income countries show key disparities at the detriment of disadvantaged population subgroups. There is a lack of scholarly evidence on the extent and reasons for the inequalities in NMRs in Angola. OBJECTIVE: The aim of this study was to assess the socio-economic, place of residence, region and gender inequalities in the NMRs in Angola. METHODS: The World Health Organization Health Equity Assessment Toolkit software was used to analyse data from the 2015 Angola Demographic and Health Survey. Five equity stratifiers: subnational regions, education, wealth, residence and sex were used to disaggregate NMR inequality. Absolute and relative inequality measures, namely, difference, population attributable fraction (PAF), population attributable risk (PAR) and ratio, were calculated to provide a broader understanding of the inequalities in NMR. Statistical significance was calculated at corresponding 95% uncertainty intervals. FINDINGS: We found significant wealth-driven [PAR = -14.16, 95% corresponding interval (CI): -15.12, -13.19], education-related (PAF = -22.5%, 95% CI: -25.93, -19.23), urban-rural (PAF = -14.5%, 95% CI: -16.38, -12.74), sex-based (PAR = -5.6%, 95% CI: -6.17, -5.10) and subnational regional (PAF = -82.2%, 95% CI: -90.14, -74.41) disparities in NMRs, with higher burden among deprived population subgroups. CONCLUSIONS: High NMRs were found among male neonates and those born to mothers with no formal education, poor mothers and those living in rural areas and the Benguela region. Interventions aimed at reducing NMRs, should be designed with specific focus on disadvantaged subpopulations.